Benign Pneumoperitoneum Following Mitral Valve Replacement

Invited commentary

To report a case of successful use of fondaparinux for bridging early after aortic and mitral mechanical heart valve replacement (MHVR). A 71-year-old female underwent aortic and mitral valve replacements with St. Jude medical bileaflet prostheses, as well as DeVega tricuspid annuloplasty and coronary artery bypass graft. Anticoagulation was initially withheld following the procedure because of thrombocytopenia, large amount of chest tube drainage (~1 L/day), and concerns regarding postoperative bleeding. The thrombocytopenia (baseline platelet count 183 x 10(3)/μL; postoperative platelet count 44 × 10(3)/μL) was thought to be a consequence of the cardiopulmonary bypass; there was a low probability of heparin-induced thrombocytopenia. However, the care team preferred to avoid heparin products and initiated fondaparinux 7.5 mg subcutaneously once daily on postoperative day 8 once the patient's platelet count had recovered to >100 x 10(3)/μL. The treatment was bridged to warfarin on postoperative day 13 and the patient was discharged home after receiving 8 days of fondaparinux. Throughout the patient's hospitalization and upon follow-up on postoperative day 31, there were no signs or symptoms of thromboembolic events or bleeding. Unfractionated heparin and low-molecular-weight heparins are the standard of care for bridging to warfarin in patients with MHVR. The use of fondaparinux following MHVR has not been studied in randomized controlled trials. In vitro studies support the effectiveness of fondaparinux in preventing thrombus formation on mechanical heart valves. However, the only data available in humans as of December 2011 are 3 case reports. Two of these case reports described the successful use of fondaparinux for anticoagulation in a patient with an aortic valve replacement. In the third case report, the patient had an aortic and mitral valve replacement. Our case report is novel because it describes the use of fondaparinux early after MHVR, which is the most critical time period for effective thromboprophylaxis. The use of fondaparinux for postoperative bridging in our patient early after combined aortic and mitral MHVR was effective. However, until studies evaluate the efficacy and safety of fondaparinux in patients with MHVR, its use should be considered only when heparin products are contraindicated.

Mechanical heart valves require anticoagulation to prevent valve-associated thrombosis and thromboembolic stroke. Oral vitamin K antagonists such as warfarin are prescribed universally; however, oral agents do not act immediately and usually require at least 5 days to achieve a therapeutic effect. Article p 564 Measurement of the prothrombin time, which is standardized by reporting the result as the international normalized ratio (INR), assesses the anticoagulant effect of warfarin. For most mechanical heart valves, the target INR ranges between 2.0 and 3.5. In the postoperative cardiac surgical setting, patients are usually started on low doses of warfarin because they tend to have impaired hepatic metabolism and suboptimal nutritional status. Even with low initial doses of warfarin, mechanical heart valve replacement patients are susceptible to excessively high INRs.1 This known exaggerated initial response to warfarin after heart valve replacement can lead to the habitual prescription of such low warfarin doses that warfarin as monotherapy may not achieve a stable and therapeutic INR for weeks after its initiation. To minimize the delay in achieving therapeutic anticoagulation, a “bridging” anticoagulant is prescribed. The “bridge” is administered parenterally, thereby providing an immediate anticoagulant effect. Traditionally, the “bridging” agent has been unfractionated heparin (UFH). More recently, physicians tend to select low-molecular-weight heparin (LMWH), even though few studies exist to validate the efficacy and safety of either LMWH or UFH in this setting. The rationale for shunning UFH has been to avoid the known perils and inconveniences of its use as a continuous peripheral intravenous infusion. UFH is rarely administered in an immediately therapeutic dose because of fear of precipitating bleeding complications. Especially in postoperative mechanical valve replacement patients, there is reluctance to follow the high dosing requirements for initial bolus and infusion regimens published in standardized nomograms. Instead, UFH is usually started in cautious small …

We report a successful treatment of massive bleeding due to spontaneous splenic rupture after mitral valve replacement. A 61-year-old man was admitted to our hospital for intermittent high fever. An echocardiogram demonstrated a large vegetation on the posterior cusp of the mitral valve and mitral regurgitation of moderate degree. Staphylococcus epidermidis was cultured from his arterial blood. He underwent a mitral valve replacement after 3 weeks of antimicrobiological therapy with penicillin G crystalline and minocycline hydrochloeide. The patient fell into hemorrhagic shock on postoperative day 11 after complaining dull pain on his left upper abdomen for 3 days. A computed tomography demonstrated a splenic rupture and massive hematoma in the retroperitoneum. A splenic arterial embolization was done before splenectomy. The blood and clot of 2800 g were sucked from peritoneal and retroperitoneal cavities. There were no mycotic aneurysms nor abscess but the torn capsule on the swelled and partially necrotic spleen. The patient discharged uneventfully on postoperative day 43. Infective endocarditis frequently causes splenic infarction but rarely splenic rupture. Anticoagulation therapy after mitral valve replacement might have emphasized the bleeding in the patient.

Background: Gastrointestinal (GI) tract perforation is a surgical emergency requiring rapid diagnosis, often via chest radiography. Artificial intelligence (AI), including large language models like ChatGPT, has potential to enhance medical imaging but its efficacy in detecting GI perforation is unclear. We compared the diagnostic accuracy of ChatGPT 3.5 and 4 with human experts in interpreting chest radiographs for GI perforation. Methods: This retrospective study, approved by the Arel University Hospital Ethics Committee (E-52857131-050.06.04-455896), analyzed 504 chest radiographs from patients diagnosed with GI perforation between 2010 and 2021. Radiographs were classified into three groups: definite GI perforation, suspicious requiring further imaging, or no perforation. Two clinicians (emergency medicine specialist and general surgeon) independently evaluated radiographs, followed by ChatGPT 3.5 and 4 using a standardized prompt. Diagnostic accuracy was assessed with chi-square tests, and decision-making times with Student’s t-test (p

EDITOR: The use of thoracic epidural anaesthesia (TEA) in patients undergoing cardiac surgery, although increasing in popularity, remains controversial [1,2]. Moreover, while relatively large series of patients undergoing coronary revascularization under TEA have been studied, a small number of cases has been reported in which TEA has been used in valvular cardiac surgery [3]. We report the successful use of TEA in a challenging case of mitral surgery, in a patient with severe co-morbidities and allergies contra-indicating the administration of non-steroidal anti-inflammatory drugs (NSAIDs) and opioids. The patient was previously rejected by other cardiosurgical centres. A 49-yr-old (157 cm, 59 kg) female with severe mitral regurgitation was scheduled for valve replacement. Co-morbidities included hypertension, a history of congestive heart failure and transient acute renal failure, pectus excavatum with severe respiratory deficit, multiple allergies (including various antibiotics, paracetamol and NSAIDs), previous transfusion reaction, glucose-6-phosphate dehydrogenase (G-6-PD) deficiency, post-thyroidectomy hypothyroidism and hypoparathyroidism. The patient was receiving amlodipine, clonidine, spironolactone, budesonide, calcium fumarate, salbutamol, beclomethasone, oxygen, l-thyroxine and calcium carbonate. She complained of fatigue and dyspnoea on minimum exertion and was orthopnoeic, with reduced chest expansion, reduced dipharagmatic mobility and abnormal sounds in the inferior pulmonary fields. Electrocardiography showed sinus rhythm and signs of left ventricular hypertrophy. Chest X-ray was consistent with the patient's cardiac and pulmonary diagnosis. Transthoracic echocardiography revealed moderate-to-severe mitral regurgitation caused by functional tethering and fibrosis of the posterior leaflet, moderate concentric left ventricular hypertrophy, hypokinetic cardiopathy with no geometric remodelling and left ventricular ejection fraction of 40%. It also showed increased pulmonary artery pressure (50 mmHg systolic), with moderate tricuspid regurgitation and mild right ventricular failure. No preoperative transoesophageal examination was performed because the patient did not tolerate the procedure. Spirometry confirmed the severe obstructive-restrictive pattern with forced expiratory volume in 1 s (FEV1) 31% and forced vital capacity (FVC) 43% of predicted. Partial pressure of O2 (PaO2) and CO2 (PaCO2) were 69 and 40 mmHg, respectively, with saturation of O2 (SaO2) 92% at arterial blood gases analysis on room air. Other biochemical and haematological parameters were within normal limits. In view of her preoperative status, it was believed that the patient would benefit from TEA. The risks and benefits were explained to her and she gave written informed consent. Epidural catheterization was performed on the day prior to surgery. Her pre-operative platelet count (390 × 109 mL−1) and coagulation (international normalized ratio (INR) 0.87, partial thromboplastin time (PTT) ratio 0.87) were within the normal range. Catheter placement was accomplished by an experienced anaesthesiologist in a high-dependency area. Monitoring included electrocardiogram, non-invasive blood pressure and pulse oximetry. The patient was positioned sitting upright and an 18-G epidural catheter was inserted at T5-T6, using the loss-of-resistance technique and a midline approach, in a single attempt. The catheter was advanced 6 cm cephalic into the epidural space. No bleeding was noted and a test dose of 2 mL of 2% lidocaine was injected. On the day of operation, the patient received her usual medication, followed by lorazepam 3 mg by mouth. Standard monitoring plus pulmonary artery catheter were applied. General anaesthesia consisted of fentanyl, midazolam, propofol, rocuronium and sevoflurane. After induction, a bolus dose of 5 mL of 1% lidocaine and fentanyl 5 μg mL−1 was administered by epidural catheter, with supplemental boluses of 3-5 mL of the same mixture throughout the operation (20 mL total amount) according to arterial pressure stability. A mitral valve replacement with mechanical prosthetic valve using moderately hypothermia (32°C) and cardiopulmonary bypass was performed. The patient was given 300 UI kg−1 of heparin and intermittent bolus doses to maintain the activated coagulation time (ACT) >480 s. At termination of bypass, normal coagulation was restored using protamine sulphate in the ratio of 1 mg kg−1 for every mg of heparin administered according to the ACT. Surgery was uneventful and no difficulties in haemostasis were noted. Weaning required inotropic support with epinephrine 0.05 μg −1kg min−1 and an enoximone 30 mg bolus plus 3 μg kg−1 min−1 continuous infusion. After the completion of the procedure, the patient was transferred to the intensive care unit. An epidural infusion of 0.2% ropivacaine and fentanyl 0.4 μg mL−1, at a rate of 4-7 mL h−1, was given as postoperative analgesia for the first 72 h. Inotropic support was progressively reduced and stopped on the first postoperative day. Also tracheal extubation was performed on the same day with good post-extubation gas exchanges in comparison with preoperative values. Good analgesia was obtained, with a pain score of 1 at rest and 3 during coughing. No parenteral opioids were required postoperatively. Neither paresthesiae nor heaviness were reported, nor any motor weakness was detected. Low-molecular-weight heparin (LMWH) 100 UI kg−1 twice daily was started on the second postoperative day as anticoagulation therapy. No oral anticoagulants were administered. The patient experienced a transient episode of atrial fibrillation that regressed after a 300 mg bolus dose of amiodarone on the third postoperative day. A pyrexia developed on the second and third days despite antibiotic prophylaxis with cefazoline. We removed the epidural catheter 12 h after a dose of LMWH and discharged the patient from ICU on the fourth postoperative day when starting oral anticoagulants. The risk-benefit ratio of applying TEA to patients undergoing cardiac surgery is a lively debated topic [1]. Many potential clinical benefits have been suggested and investigated, but effects on clinical outcomes remain to be determined and compared with the risk of epidural haematoma [1,4,5]. The only clear benefit of using TEA in cardiac surgical patients is enhanced postoperative analgesia [6]. Respiratory therapy and aggressive control of postoperative pain were considered key components in the management of this high-risk patient, and TEA played an important role in view of the long list of patient co-morbidietes. A cautious application of TEA [7] provided excellent postoperative analgesia without parenteral opioids and NSAIDs, and allowed a rapid recovery of consciousness, a reduced time to tracheal extubation and an early active respiratory physiotherapy and mobilization, thus simplifying postoperative management in this complex patient. Acknowledgements The study was conducted exclusively with departmental sources. There is no conflict of interest by any of the authors. We thank Giardina Giuseppe, RN and Castelnuovo Lara, RN for the care provided to this patient and for revising the manuscript. G. Crescenzi R. D. Covello G. Landoni M. De Luca G. Fracasso M. Melone S. M. Serini E. Bignami C. Rosica A. Zangrillo 1Department of Cardiothoracic and Vascular Anesthesia Istituto Scientifico San Raffaele Università Vita-Salute San Raffaele Milano, Italy

A 72-year-old woman presented with exertional dyspnea. Echocardiography revealed severe mitral valve stenosis; therefore, mitral valve replacement was performed using a bioprosthetic valve. However, left ventricular wall rupture occurred following mitral valve replacement. Under re-cardiac arrest, we found a left ventricular tear under the posterior annulus of the mitral valve. We repaired the left ventricular muscle using a bovine pericardial patch and implanted a bioprosthetic valve again. Postoperatively, we implanted an Impella 5.0 heart pump through the right axillary artery to ensure left ventricular wall unloading. Systemic blood flow depended almost completely on mechanical circulatory assistance until postoperative day 3. After the fourth postoperative day, we started weaning the patient from Impella 5.0. Finally, it was completely discontinued on the sixth postoperative day. After that, the patient's condition was stable, and she was discharged 44days postoperatively. Impella 5.0 is a potentially beneficial device for left ventricular unloading in patients with left ventricular wall rupture following mitral valve replacement.

Background: Mitral valve replacement (MVR) is a surgical procedure that is often performed in patients with severe mitral valve disease, to replace the damaged valve with a new artificial valve. Left Atrial Volume Index (LAVI) is a measurement of the size of the left atrium of the heart, normalized to the body surface area which is often used as an indicator of left atrial enlargement, which is a common finding in patients with mitral valve disease. There is a significant relationship between LAVI and Atrial Fibrillation (AF) after MVR in patients with mitral valve disease.
 Aim of the study: The aim of this study was to evaluate the relationship between LAVI and the occurrence of atrial fibrillation after mitral valve replacement in patients with mitral valve diseases. Methods: This prospective observational study was conducted in the department of Cardiac Surgery, National Institute of Cardiovascular Diseases (NICVD), Dhaka from March, 2018 to February, 2019. Total 60 patients were divided into two groups, out of them 30 patients had LAVI e”39 ml/m² (Group-A) and 30 patients had LAVI d” 39ml/m² (Group-B).
 Result: In patients with post-operative AF after MVR, was evaluated by ECG in the presence or absence of pwave and irregular R-R interval and measurement of LAVI more or less than cutoff value 39 ml/m². On postoperative day 3, 7 (23.33%) patients in Group A and 02(6.66%) patients in Group B developed post-operative AF. In Group A there was reduction in the LAVI but not below the cutoff value whereas in Group B, the LAVI was reduced below the cutoff value (< 39 ml/m2). On overall evaluation, after mitral valve replacement increased LAVI is significantly associated with post-operative AF occurrence and is a better predictor than LA diameters. From univariate analysis in our cohort, high inotropes support, MVT, ACT, CPB time and postoperative LAVI were significantly associated with occurrence of AF. But multiple logistic regression analysis revealed postoperative LAVI to be only significant predictor of occurrence of AF after Mitral valve replacement.
 Conclusion: Our study shows that postoperative LAVI measured by 2-D echocardiography is positively and independently associated with the occurrence of postoperative AF following MVR. Moreover, clinical risk factors are fairly good predictors of the occurrence of AF after MVR, but postoperative LAVI was the most significant independent predictor of postoperative AF in our study.
 Bangladesh Heart Journal 2023; 38(1): 38-45

A 49-year-old man with mitral regurgitation developed chylopericardium after mitral valve replacement. On postoperative day (POD) 1, the patient was started on a regular diet. On POD 2, drainage from retrosternal and intrapericardial tubes increased, becoming turbid and milky. Because the triglyceride concentration was high at 197 mg/dl, we diagnosed the condition as chylopericardium. The patient was given nothing by mouth for 2 days and, from POD 4, received a low-fat diet, after which drainage cleared and volume decreased. The 2 drainage tubes were removed on POD 6, and he was discharged without complications on POD 18.

Even if acute abdomen is associated with gastrointestinal (GI) perforation in more than 90% of cases, spontaneously perforated pyometra is a rare and misleading cause that gynecologists and general surgeons should suspect in elderly postmenopausal women. We report one case of diffuse peritonitis caused by spontaneous uterine perforation. A 94-year-old postmenopausal female was admitted to emergency department with signs of diffuse peritonitis and seven days history of abdominal pain. Abdominal contrast- enhanced CT-scan showed a large amount of ascites and a small amount of intraperitoneal free-air. One hour after the admission septic shock developed and emergency laparotomy was performed for suspected GI perforation. During laparotomy about 1500 mL of purulent, malodorous but not-fecaloid fluid was found in peritoneal cavity, without evidence of GI perforation. A 10 mm perforation on the anterior part of the uterine fundus was found. A total abdominal hysterectomy with a bilateral salpingo-oophorectomy was performed. Patients died on postoperative day four despite intensive care for multi-organ failure due to septic shock. The hysto-pathology examination showed absence of cancer. Pyometra perforation is a rare cause of acute abdomen with a not negligible mortality and it should be considered in the differential diagnosis of acute abdomen, especially in elderly patients. The aim of the study is to report our personal experience and a review of the literature of spontaneous perforation of pyometra in patients with no evidence of malignancy.

A free floating ball thrombus in the left atrial cavity

We report a 28-year-old white female who suffered significant aortic insufficiency (AI) following mitral valve (MV) replacement for endocarditis. The patient had history of rheumatoid arthritis and presented to our emergency department with a 3-month history of dyspnea, orthopnea, fevers and weight loss, worsening over 2 weeks, for which she took intermittent acetaminophen. On admission, vital signs revealed blood pressure of 99/70 mm Hg, heart rate of 120 beats/minute, and temperature of 98.8 °F; her weight was 100 lbs. Physical exam revealed a thin and pale female. Cardiac auscultation revealed regular tachycardic rhythm with a third heart sound, and a short early systolic murmur at the left lower sternal border without radiation. Lungs revealed right lower lobe rhonchi. Initial pertinent laboratory evaluation revealed hemoglobin 9.6 g/dL and white blood cell count 17,500/μL. Renal function was normal, and hepatic enzymes were mildly elevated. Chest radiogram revealed right lower lobe infiltrate. Blood cultures revealed Enterococcus faecalis. Two-dimensional echocardiogram revealed large multilobed vegetation attached to the anterior MV leaflet with severe mitral regurgitation (MR), otherwise normal left ventricular systolic function. She was started on appropriate antibiotics and underwent MV replacement with 25-mm On-X prosthesis. She was noted post-operatively to have prominent systolic and diastolic murmurs. Repeat echocardiogram revealed normal mitral prosthesis function, with new moderately severe AI. Transesophageal echocardiogram revealed AI originating from a tethered non-coronary cusp, due to a suture preventing proper cusp mobility. The patient declined further surgery. She recovered slowly and was discharged to inpatient rehabilitation 4 weeks later. This case highlights the importance of vigilance to this potential serious complication of valve surgery with regard to diagnosis and treatment to prevent long-term adverse consequences.

To evaluate the functional capacity following mitral valve replacement in the early postoperative period and to determine the correlation of biventricular function and residual pulmonary artery hypertension (PAH) to the functional capacity. On the seventh postoperative day, 53 patients who underwent mitral valve replacement with preoperative diagnosis of PAH underwent a 2-dimensional echocardiographic and Doppler examination for the assessment of right ventricular systolic pressure, along with right ventricular (RV) and left ventricular (LV) myocardial performance indices (MPIs). These assessments were followed by a 6-Minute Walk Test. Five patients were eventually withdrawn from the study. The diminished functional capacity (51.6% ± 4.1% of predicted 6-Minute Walk Test distance for age, gender, weight, and height) significantly correlated with biventricular dysfunction evident from elevated RVMPI (0.35 ± 0.09) and LVMPI (0.52 ± 0.11) (for both Ps ≤ .001). Furthermore, the residual PAH, with mean right ventricular systolic pressure of 37 ± 11 mm Hg, showed negative correlation with the functional capacity (P ≤ .001). In addition, LVMPI had strong association with RVMPI (P ≤ .001). Linear regression analysis demonstrated that LVMPI and right ventricular systolic pressure were independent predictors of functional capacity. The RV and LV function, as quantified by MPI, and the degree of residual PAH are associated with functional capacity impairment after mitral valve replacement, with LVMPI and residual PAH as the independent predictorsqbetween RV and LV performance indices indicate that ventricular interactions contribute to the functional capacity impairment in these patients.

Mitral valve–sparing operation in subaortic stenosis caused by anomalous papillary muscle and discrete subaortic stenosis

Systolic Heart Failure in a Patient With Hypertrophic Obstructive Cardiomyopathy